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Background: Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia., Methods: In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM)., Findings: Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences., Interpretation: Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits., Funding: Institute for Safety, Compensation, and Recovery Research (Australia)., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Question: What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?, Design: A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention., Participants: Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand., Intervention: Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15minutes of one-to-one hand therapy three times per week without functional electrical stimulation., Outcome Measures: The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks., Results: Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean (SD) modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9)., Conclusion: Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia., Registration: Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930. [Harvey LA, Dunlop SA, Churilov L, Galea MP, Spinal Cord Injury Physical Activity (SCIPA) Hands On Trial Collaborators (2017) Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial. Journal of Physiotherapy 63: 197-204]., (Copyright © 2017 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Question: What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?, Design: A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention., Participants: Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand., Intervention: Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1 hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15 minutes of one-to-one hand therapy three times per week without functional electrical stimulation., Outcome Measures: The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks., Results: Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9)., Conclusion: Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia., Registration: Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Question: What is the body temperature response of healthy pregnant women exercising at moderate intensity in an aqua-aerobics class where the water temperature is in the range of 28 to 33 degrees Celsius, as typically found in community swimming pools?, Design: An observational study., Participants: One hundred and nine women in the second and third trimester of pregnancy who were enrolled in a standardised aqua-aerobics class., Outcome Measures: Tympanic temperature was measured at rest pre-immersion (T1), after 35minutes of moderate-intensity aqua-aerobic exercise (T2), after a further 10minutes of light exercise while still in the water (T3) and finally on departure from the facility (T4). The range of water temperatures in seven indoor community pools was 28.8 to 33.4 degrees Celsius., Results: Body temperature increased by a mean of 0.16 degrees Celsius (SD 0.35, p<0.001) at T2, was maintained at this level at T3 and had returned to pre-immersion resting values at T4. Regression analysis demonstrated that the temperature response was not related to the water temperature (T2 r = -0.01, p = 0.9; T3 r = -0.02, p=0.9; T4 r=0.03, p=0.8). Analysis of variance demonstrated no difference in body temperature response between participants when grouped in the cooler, medium and warmer water temperatures (T2 F=0.94, p=0.40; T3 F=0.93, p=0.40; T4 F=0.70, p=0.50)., Conclusions: Healthy pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic exercise conducted in pools heated up to 33 degrees Celsius. The study provides evidence to inform guidelines for safe water temperatures for aqua-aerobic exercise during pregnancy., (Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Restoration of elbow extension, grasp, key pinch, and release are major goals in low-level tetraplegia. Traditionally, these functions are achieved using tendon transfers. In this case these goals were achieved using nerve transfers. We present a 21-year-old man with a C6 level of tetraplegia. The left upper limb was treated 6 months after injury with a triple nerve transfer. A teres minor nerve branch to long head of triceps nerve branch, brachialis nerve branch to anterior interosseous nerve, and supinator nerve branch to posterior interosseous nerve transfer were used successfully to reconstruct elbow extension, key pinch, grasp, and release simultaneously., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Pelvic organ prolapse is common and is strongly associated with childbirth and increasing age. Women with prolapse are often advised to do pelvic floor muscle exercises, but evidence supporting the benefits of such exercises is scarce. We aimed to establish the effectiveness of one-to-one individualised pelvic floor muscle training for reducing prolapse symptoms., Methods: We did a parallel-group, multicentre, randomised controlled trial at 23 centres in the UK, one in New Zealand, and one in Australia, between June 22, 2007, and April 9, 2010. Female outpatients with newly-diagnosed, symptomatic stage I, II, or III prolapse were randomly assigned (1:1), by remote computer allocation with minimsation, to receive an individualised programme of pelvic floor muscle training or a prolapse lifestyle advice leaflet and no muscle training (control group). Outcome assessors, and investigators who were gynaecologists at trial sites, were masked to group allocation; the statistician was masked until after data analysis. Our primary endpoint was participants' self-report of prolapse symptoms at 12 months. Analysis was by intention-to-treat analysis. This trial is registered, number ISRCTN35911035., Findings: 447 eligible patients were randomised to the intervention group (n=225) or the control group (n=222). 377 (84%) participants completed follow-up for questionnaires at 6 months and 295 (66%) for questionnaires at 12 months. Women in the intervention group reported fewer prolapse symptoms (ie, a significantly greater reduction in the pelvic organ prolapse symptom score [POP-SS]) at 12 months than those in the control group (mean reduction in POP-SS from baseline 3.77 [SD 5.62] vs 2.09 [5.39]; adjusted difference 1.52, 95% CI 0.46-2.59; p=0.0053). Findings were robust to missing data. Eight adverse events (six vaginal symptoms, one case of back pain, and one case of abdominal pain) and one unexpected serious adverse event, all in women from the intervention group, were regarded as unrelated to the intervention or to participation in the study., Interpretation: One-to-one pelvic floor muscle training for prolapse is effective for improvement of prolapse symptoms. Long-term benefits should be investigated, as should the effects in specific subgroups., Funding: Chief Scientist Office of the Scottish Government Health and Social Care Directorates, New Zealand Lottery Board, and National Health and Medical Research Council (Australia)., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Previous research on developmental outcomes of infants with congenital heart disease (CHD) has shown delays in both cognitive and motor skills., Aims: To describe outcomes on the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) for infants with CHD and to compare those findings to published results for similar samples of infants assessed on the 2nd edition of the Bayley Scales (BSID-II)., Study Design: Prospective cohort., Participants and Outcome Measures: Of 50 infants with CHD who participated in this longitudinal study (2006-2008) at the Royal Children's Hospital in Melbourne, Australia, 47 were assessed on the Bayley-III (median age=24.5 months), administered by a psychologist or neonatologist. Although neither assessor was blind to the CHD diagnosis, they were unaware of results of previous developmental assessments conducted in this longitudinal study., Results: For the Bayley-III cognitive composite score, 17.0% of infants showed mild delays (1-2 SD below the mean), 2.1% had moderate delays (2-3 SD below the mean), and none had severe delays (greater than 3 SD below the mean). Motor composite scores showed mild delays in 10.9% of infants and moderate delays in 2.2%; none had severe motor delays. These findings differ from study results using the BSID-II in similar infants., Conclusions: The Bayley-III may underestimate developmental delay in 2-year-old children with CHD when compared to results of similar children tested at 12-36 months of age on the BSID-II., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: This chapter presents modalities of physical therapy used in optimizing sensorimotor recovery from nervous system injury., Methods: A brief historical perspective, rationale, indications for application, and evidence of effectiveness of various physical treatment modalities is provided., Results: Many of the facilitatory and inhibitory techniques used in the past are no longer used, as they were based on an understanding of recovery after nervous system injury that is now outdated. There has been a paradigm shift in the management of people with neurological dysfunction. In particular there has been a reduction in focus on the positive features or the upper motor neuron syndrome, such as spasticity, and an increasing emphasis on active, task-related practice of functional tasks., Conclusion: Physical therapy for people with neurological disorders has undergone a paradigm shift as a result of new knowledge about motor control, skill acquisition, and recovery of function after injury. Future research should address new applications of electrical stimulation and whole body vibration as well as the optimal dosage and timing of interventions., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Preterm infants are recognised as developing at a significantly slower rate than their full-term peers and with different movement quality., Aim: This study aimed to describe the longitudinal gross motor trajectories of these infants in the first 18 months of (corrected) age and investigate factors associated with gross motor development., Study Design: A longitudinal study was conducted with convenience samples of 58 preterm infants born < or = 29 weeks of gestation and 52 control full-term infants in Australia., Outcome Measures: The infants were assessed at 4, 8, 12 and 18 months of (corrected) age using the Alberta Infant Motor Scale (AIMS)., Results: Forty-six preterm and 48 control infants completed all four assessments. The preterm group scored significantly lower on various sub-scores at all age levels. Almost half of the preterm infants demonstrated less progression in the sit sub-scale from 4 to 8 months (corrected) age, possibly due to an imbalance between flexor and extensor strength in the trunk. At 12 and 18 months of (corrected) age, lack of rotation and fluency in their movements were evident in some preterm infants. Presence of intra-ventricular haemorrhage and chronic lung disease were associated with poor motor performance at 4 months and use of postnatal steroids was associated with poor motor performance at 4, 8 and 18 months of corrected age., Conclusion: The imbalance between flexor and extensor muscle strength in preterm infants had a stronger impact on motor development than usually expected. The AIMS appears to be a sensitive assessment tool to demonstrate the unique movement characteristics in this preterm cohort., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

The 2D PEAK Motus motion analysis system was used to measure the sagittal lumbofemoral rhythm during active hip (knee) flexion in standing in 34 healthy older adults whose movement may be influenced by age-related changes in the neuromusculoskeletal system. When the thigh was raised, the lumbar spine moved concurrently with the hip joint throughout the movement. Approximately 5 degrees of initial hip flexion occurred before 1 degrees of lumbar flexion. Overall, the lumbar spine contributed 26.6% (29.3 degrees ) of the total thigh movement (pelvis+hip joint) during the upward (110.2 degrees ) movement phase. Compared to children and young adults, older adults demonstrated some age-related differences in sagittal lumbofemoral rhythm, including decreased hip flexion and a large variation in the hip-to-lumbar movement ratio. Clinicians and exercise instructors need to be aware of the concurrent movement interaction between the hip joint and lumbar spine when measuring hip flexion range or when instructing abdominal, hip, or lumbar exercises. The potential influence of limited range of motion of either hip or lumbar component on the movement should also be addressed.

A revised model of skin marker placement with the two-dimensional (2D) PEAK Motus system was used to investigate the effect of aging on sagittal range of spinal motion. Twenty-four healthy young adults and twenty-two healthy older adults were videotaped while performing the movements of flexion and extension in each spinal region--cervical, thoracic and lumbar spine. Alternative movement tests that may allow a greater range of motion (ROM) for thoracic extension and lumbar flexion were also investigated. Older adults demonstrated significantly decreased flexion/extension ranges in the cervical, thoracic and lumbar spine. The movement of cat-stretch in the all-fours position allowed greater thoracic extension, and the movement of toe-touch in standing permitted greater lumbar flexion. This study provides reference data for sagittal ranges of spinal motion in healthy young and older adults as measured by a 2D imaged-based system. The sagittal model of skin marker placement used in this study can have a broader application for ROM measurement in the clinical setting using a digital camera and freely downloadable software.

Objective: Bilateral deficit is the increase in reaction time during bilateral activation compared to unilateral activation. This has been reported extensively for the limb muscles and is argued to be due to concurrent inhibition through transcallosal pathways. Unlike the limb muscles, the axial muscles are commonly activated bilaterally during functional tasks and have bilateral projections to their motoneurones. Thus it is reasonable to hypothesise that there will be no bilateral deficit for these muscles., Methods: Recordings of electromyographic (EMG) activity were made using surface electrodes placed bilaterally over the abdominal muscles in eight healthy right-handed subjects. Subjects performed either right or left pelvic elevation (unilateral abdominal activation), or posterior pelvic tilt (bilateral abdominal activation) "as fast as possible" in response to an auditory tone. Movements were performed as either a simple or choice reaction time task., Results: Bilateral activation induced significantly longer reaction time than unilateral activation, and was observed during both simple and choice reaction time tasks., Conclusions: The results demonstrate that reaction time is delayed during bilateral activation of the abdominal muscles., Significance: These findings suggest that bilateral deficit is present for the axial muscles. This could be mediated through inhibition at various levels of the nervous system or variations in postural demand.